BACKGROUND ON CEREBRAL PALSY
Cerebral palsy is a non-progressive neurological disorder in which many aspects of human motor operation are affected-from the alignment of foot bones, to the length of tendons, to the ability of one’s brain to receive and send motion-related information. The inability of the brain to correctly communicate with neurons represents an overall loss of motor control. Combine this with physical deformations and abnormal reflex activity, and you have the stereotypical cerebral palsied person who moves, walks and talks in seemingly strange ways. There are three basic types of cerebral palsy: spastic cerebral palsy, which is the most common type and whose primary motor symptom is spasticity; ataxic cerebral palsy, which affects motor functioning without spasticity; and athetoid cerebral palsy, which is characterized by issues with muscle tone. Within these classifications of the disease, there are several types of cerebral palsy based on the extent to which one’s body is affected. In hemiplegic cerebral palsy, only one side of the body is (primarily) affected. In diplegic cerebral palsy, the lower half of the body is more affected than the upper half, and in quadraplegic (or tetraplegic) cerebral palsy, the whole body is affected.
Cerebral palsy is a disease that affects many people from all over the world. It develops as a result of brain damage (especially white matter damage) that occurs while in the womb, during birth, or soon after birth. The disease impedes normal central nervous system behavior, and therefore results in loss of motor control-the most well-known symptom of cerebral palsy. This loss of motor control leads to specific physical impairments, such as trouble walking, trouble speaking clearly and difficulties with feeding. However, the physical limitations that result from cerebral palsy are almost always accompanied by other impairments cognitive in nature, such as intellectual deficits and flawed sensory awareness. Since the disease makes typical day-to-day activities, such as eating and getting from one place to another, very challenging, cerebral palsy greatly limits the independence of its sufferers. It also makes learning in a normal classroom environment and socializing with people of the same age difficult. Therefore, finding and implementing preventative measures as well as effective methods for managing the disease are important goals of research concerning cerebral palsy.
1. The epidemiology of cerebral palsy: Incidence, impairments and risk factors
PURPOSE: Describing the epidemiology of cerebral palsy (CP), its impairments and risk factors. METHOD: Literature review 1965-2004. Search terms: Cerebral palsy, incidence, prevalence, impairments, risk factors. RESULTS: In the last 40 years the prevalence of CP has risen to well above 2.0 per 1000 life births. In this time span the proportion of low-birthweight infants rose, the proportion of diplegia decreased, while the proportion of hemiplegia increased. CP is more prevalent in more deprived socio-economic populations. The majority of people with CP have the spastic syndrome of which the diplegic group is the smallest. Dependent on the subgroup of CP, 25-80% have additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. Epilepsy is present in 20-40%; it is most common among the hemi- and tetraplegics. Sensibility of the hands is impaired in about half. Chronic pain is reported by more than a quarter of the adults. Up to 80% have at least some impairment of speech. Low visual acuity is reported in almost three-quarters of all children. Half of all children have gastrointestinal and feeding problems. Stunted growth occurs in a quarter, while under- or overweight problems are present in half of the children. Almost 70% of people with spastic CP have abnormal brain CT findings; abnormal cranial ultrasounds is most strongly associated with hemiplegia, normal cranial ultrasounds with diplegia. The most important risk factors for CP are low birthweight, intrauterine infections and multiple gestation.
[Odding, E., Roebroeck, M. E. & Stam, H. J. (2006). The epidemiology of cerebral palsy: Incidence, impairments and risk factors. Disability and Rehabilitation, 28(4), 183-91.]
2. Cerebral palsy: Introduction and diagnosis (part I)
Cerebral palsy (CP), a static, nonprogressive disorder caused by brain insult or injury in the prenatal, perinatal, and postnatal time period, is the major developmental disability affecting function in children. It is characterized by the inability to normally control motor functions, and it has the potential to have an effect on the overall development of a child by affecting the child's ability to explore, speak, learn, and become independent. Effective management can improve the quality of life for the child and family. The first step for the nurse practitioner is to understand the definition of CP and how to make the diagnosis. This article is part one of two articles on CP. The first article will focus on the diagnosis of CP, and the second will focus on a review of systems approach for management as well as resources for the family and practitioner.
[Jones, M. W., Morgan, E., Shelton, J. E. & Thorogood, C. (2007). Cerebral palsy: Introduction and diagnosis (part I). Journal of Pediatric Health Care, 21(3), 146-52.]
3. Cerebral palsy
Cerebral palsy (CP) is a group of disorders of movement and posture resulting from nonprogressive disturbances of the fetal or neonatal brain. More than 80% of cases of CP in term infants originate in the prenatal period; in premature infants, both prenatal or postnatal causes contribute. The most prevalent pathological lesion seen in CP is periventricular white matter injury (PWMI) resulting from vulnerability of the immature oligodendrocytes (pre-OLs) before 32 wk of gestation. PWMI is responsible for the spastic diplegia form of CP and a spectrum of cognitive and behavioral disorders. Oxidative stress and excitotoxicity resulting from excessive stimulation of ionotropic glutamate receptors on preOLs are the most prominent molecular mechanisms for PWMI. Asphyxia around the time of birth in term infants accounts for less than 15% of CP in developed countries but the incidence is higher in underdeveloped areas. Asphyxia causes a different pattern of brain injury and CP than is seen after preterm injuries. This type of CP is associated with the clinical syndrome of hypoxic-ischemic encephalopathy shortly after the insult, and the cortex, basal ganglia, and brainstem are selectively vulnerable to injury. Experimental models indicate that neurons in the neonatal brain are more likely to die by delayed apoptosis extending over days to weeks than those in the adult brain. Neurons die by glutamate-mediated excitotoxicity involving downstream caspase-dependent and caspase-independent cell death pathways. Recent reports indicate that males and females preferentially utilize different pathways. Clinical trials indicate that mild hypothermia reduces death or disability in term infants following asphyxia and basic research suggests that this approach might be combined with pharmacological strategies in the future.
[Johnston, M. V. & Hoon, A. H. Jr. (2006). Cerebral palsy. Neuromolecular Medicine, 8(4), 435-50.]
4. Review of cerebral palsy, Part 1: Description, incidence, and etiology
Cerebral palsy (CP) is a nonprogressive disorder of motor function. Although it has been recognized for more than a century, much remains unknown regarding its etiology. It has been estimated that 17 to 60 percent of the cases of CP have no known perinatal or neonatal complications. Undocumented antenatal events may cause brain damage or increase the infant's vulnerability to future events. The prevalence of CP has remained relatively constant; however, its incidence in the preterm population has increased with the improving survival of the very low birth weight infant.
[Davis, D. W. (1997). Review of cerebral palsy, Part 1: Description, incidence, and etiology. Neonatal Network, 16(3), 7-12.]
5. Review of cerebral palsy, Part II: Identification and intervention
Cerebral palsy (CP) can be identified and classified by thorough evaluation using multiple assessment techniques. Clinical signs, symptoms, associated disorders, and methods used to evaluate developmental disorders have been described. Because some of the previously used evaluation methods have not been adequate tools, new ways of measuring outcome have been proposed. Multidisciplinary treatment protocols have been recommended. Simplistic plans of care will not be appropriate because of the complexity of the disorder(s) and the unique characteristics of the individual and family. Therefore, thoughtful and individualized plans of care that may include multiple surgical and nonsurgical interventions must be developed for each child with CP. In addition, more data are needed, using new evaluation techniques, to determine the efficacy of early intervention.
[Davis, D. W. (1997). Review of cerebral palsy, Part II: Identification and intervention. Neonatal Network, 16(4), 19-25.]
6. Cerebral palsy: Medical aspects
Cerebral palsy describes a wide spectrum of motor problems caused by a nonprogressive lesion of the developing brain. It is variably associated with a variety of other developmental and medical problems that present challenges to parents and care providers alike. This article provides an overview of etiology and diagnosis, with a system-based discussion of management.
[Dodge, N. N. (2008). Cerebral palsy: Medical aspects. Pediatric Clinics of North America, 55(5), 1189-207, ix.]
7. Cerebral palsy: A comprehensive review
Cerebral palsy is a broad range of static, nonprogressive motor disabilities that present from birth or early childhood as a result of injury to neuromotor components of the central nervous system. Motor performance is normally coordinated via communication between the cerebral cortex, thalamus, basal ganglia, brain stem, cerebellum, spinal cord, and communicating sensori-motor pathways. This complex network lends itself to injury at many different levels. Etiologies are numerous and can occur during the prenatal, perinatal, and postnatal periods. The severity of the neurologic deficit and the clinical manifestations are varied depending on the time, location and nature of the original injury. In order to approach cerebral palsy systematically, the primary health care practitioner must be prepared to recognize neuromotor deficits, diagnose and classify the type of disorder, and implement a methodical treatment plan. The purpose of this article is to review the etiology, pathophysiology, diagnostic classification (Swedish system), clinical manifestations, and therapeutic management of cerebral palsy and prepare the advanced practice nurse to care for the individual and family.
[Dzienkowski, R. C., Smith, K. K., Dillow, K. A. & Yucha, C. B. (1996). Cerebral palsy: A comprehensive review. The Nurse Practitioner, 21(2), 45-8, 51-4, 57-9.]
8. Cerebral palsy
Cerebral palsy (CP) is the leading cause of childhood disability. This article reviews common presentations of CP and its possible causes. The management of common problems seen in affected children is discussed in a system-based approach. Many treatment options are available for CP, with varying degrees of evidence and acceptance. As individuals who have CP transition into adulthood, they face unique issues that are not well recognized in the medical community. This article briefly reviews the psychosocial impact of this chronic disease on individuals and their caregivers and family.
[Green, L. B. & Hurvitz, E. A. (2007). Cerebral palsy. Physical Medicine and Rehabilitation Clinics of North America, 18(4), 859-82, vii.]
9. Cerebral palsy—definition, classification, etiology and early diagnosis
Cerebral palsy is a common neurodevelopmental condition encountered by pediatricians. The condition may present itself in many different clinical spectra. The etiological and risk factors are many and an awareness of the interplay of multiple factors in the causation of CP is crucial. In many cases, the cause of Cerebral palsy may not be apparent. Cerebral palsy is invariably associated with many deficits such as mental retardation, speech and language and oromotor problems. A thorough neurodevelopmental assessment of the child with Cerebral Palsy should include evaluation of associated deficits so that a comprehensive early intervention program an be planned and executed.
[Sankar, C. & Mundkur, N. (2005). Cerebral palsy—definition, classification, etiology and early diagnosis. Indian Journal of Pediatrics, 72(10), 865-8.]
10. Cerebral palsy: An overview
The presentation of cerebral palsy can be global mental and physical dysfunction or isolated disturbances in gait, cognition, growth, or sensation. It is the most common childhood physical disability and affects 2 to 2.5 children per 1,000 born in the United States. The differential diagnosis of cerebral palsy includes metabolic and genetic disorders. The goals of treatment are to improve functionality and capabilities toward independence. Multispecialty treatment teams should be developed around the needs of each patient to provide continuously updated global treatment care plans. Complications of cerebral palsy include spasticity and contractures; feeding difficulties; drooling; communication difficulties; osteopenia; osteoporosis; fractures; pain; and functional gastrointestinal abnormalities contributing to bowel obstruction, vomiting, and constipation. Valid and reliable assessment tools to establish baseline functions and monitor developmental gains have contributed to an increasing body of evidenced-based recommendations for cerebral palsy. Many of the historical treatments for this ailment are being challenged, and several new treatment modalities are available. Adult morbidity and mortality from ischemic heart disease, cerebrovascular disease, cancer, and trauma are higher in patients with cerebral palsy than in the general population.
[Krigger, K. W. (2006). Cerebral palsy: An overview. American Family Physician, 73(1), 91-100.]